Dissociative disorders

Dissociative disorders show up in trauma-heavy cases, and the exam rewards the counselor who recognizes dissociation, rules out its look-alikes, and refuses to rush into trauma processing.

The set at exam depth (paraphrased):

• Dissociative identity disorder (DID): a disruption of identity involving two or more distinct personality states (in some cultures described as possession), with marked discontinuity in sense of self and agency, plus recurrent gaps in memory for everyday events, personal information, or traumatic events that go beyond ordinary forgetting. Causes distress or impairment. Not part of a broadly accepted cultural or religious practice, not a child's imaginary playmate or fantasy play, and not due to a substance or medical condition (such as seizures).
• Dissociative amnesia: inability to recall important autobiographical information, usually traumatic or stressful, beyond ordinary forgetting. Specifier with dissociative fugue: purposeful travel or bewildered wandering tied to the amnesia.
• Depersonalization/derealization disorder: persistent or recurrent feeling of being detached from one's own mind or body (depersonalization) and/or of the surroundings seeming unreal or dreamlike (derealization), with reality testing intact.
• No minimum duration is set for these diagnoses; the hinge is the pattern plus distress or impairment.

Hinge differentials:

• PTSD with dissociative symptoms — full PTSD criteria are met, and the dissociation is depersonalization or derealization, not separate identity states.
• Borderline personality disorder — unstable self-image, not distinct identity states with amnesia barriers between them.
• Psychotic disorders — voices in DID are typically experienced as internal and reality testing is otherwise preserved; psychosis brings fixed delusions and broader disorganization.
• Seizure disorders — episodic gaps with automatisms warrant neurological referral.
• Substance or medication effects — dissociation limited to intoxication or withdrawal, or resolving once use stops.

On the NCMHCE: Screen for suicide risk and self-harm, which are common, and for ongoing abuse or current unsafe relationships. Gather collateral reports of lost time or of being called by another name. Rule out substances and refer for medical or neurological evaluation when episodes look seizure-like. Treatment is phase-oriented: (1) safety, stabilization, and grounding skills; (2) trauma processing only once the client is stable; (3) integration and rehabilitation. When a client discloses a new alter or an angry internal voice, the counselor slows the pace and attends to safety rather than pressing for trauma detail. Respect cultural and religious frameworks for possession or trance before labeling them pathological.

Clinical Pearl: Distinct identity states plus amnesia separates DID from borderline personality disorder and PTSD. Stabilization comes before trauma processing.